Your Concern is Ours

We are here to help, and are attentive to your needs. Print out this form, put a check mark next to the statements that concern you or describe how you feel. Please share this or any other information with your dental team. We will help you.

I gag easily

I feel out of control when I am lying down in the dental chair

I have not been to the dentist for a long time and I feel uncomfortable about what will say or think about my teeth and my dental hygiene

I know I have bad habits that are causing harm to my dental health. I am afraid I might not be able to break them

Pain relief is a top priority to me

I don’t like shots, or I’ve had a bad reaction to shots

Please tell me what I need to know about my mouth so I can make an informed decision

My teeth are very sensitive

I don’t like the sound of that tool that makes the picking and scraping noise

I don’t like cotton in my mouth

I hate the noise of the drill

Please respect my time. I don’t want to be left sitting in the reception area

I want to know the cost up front. No money surprises, please

I have difficulty listening and remembering what I hear while sitting in the dental chair